health equity – The Early Career Voice

On Demand: Health Equity at #AHA21

December 27, 2021December 17, 2021 Andi Shahu, MD, MHS

As you may know, health equity was a major focus of the AHA 2021 Scientific Sessions, with numerous sessions that focused on cardiovascular health disparities, equity in treatment of cardiovascular disease and plenty of original health equity research. Here is a run-down of some great presentations about important topics in cardiovascular health equity from #AHA21, all of which are still available for viewing at your leisure ON DEMAND! [Please note that this list by no means comprehensive; there were many other amazing presentations which I did not have space to include here].

Fixing the Root Cause: Addressing Systemic Racism and Social Determinants of Health in Heart Failure [Oral Presentation]

This excellent and comprehensive presentation by Dr. Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA showcases data from numerous studies that have found racial disparities in heart failure incidence or heart failure outcomes, vast racial disparities in access to advanced heart failure care (such as heart transplant or left ventricular assist devices), racial and gender bias in treatment of heart failure and strategies for advancing equity in treatment of heart failure. This presentation can be found in the Embracing the Melting Pot to Reduce Heart Failure: Genetics and Social Determinants of Health Session.

Association Between Community-Level Violent Crime and Cardiovascular Mortality in Chicago – A Longitudinal Analysis [Oral Presentation]

This study, conducted by Eberly et al, utilized data from the Illinois Department of Public Health and Chicago Police Department to examine the association between longitudinal changes over three time periods from 2000 to 2014 in violent crime and cardiovascular mortality rates (such as total cardiovascular mortality or coronary artery disease mortality) at the community level in Chicago, IL. They found that decrease in a community’s violent crime rates was significantly associated with a decrease in cardiovascular and coronary artery disease mortality rates. This study was presented in the Social Determinants of Cardiovascular Health Session.

Race, eGFR, and Cardiovascular Risk: A Tale of Modern Structural Racism [Oral Presentation]

This wonderful talk by Dr. Nwamaka Eneanya, MD, MPH, FASN provides a comprehensive overview of an incredibly timely and important topic. In this presentation, Dr. Eneanya establishes a clear throughline between structural racism, utilization of race in calculation of eGFR, resulting racial disparities in access to chronic kidney disease-related care (e.g. dialysis or kidney transplantation) and racial disparities in CKD-related outcomes, as well as recommendations for future non-race based approaches to define and manage chronic kidney disease. This presentation can be found in the Race, Bias and Barriers in the Cardiovascular Care of Patients with CKD Session.

Racial and Gender Differences in Lifetime Healthcare Costs Across Cardiovascular Risk Factors [Oral Presentation]

This study, conducted by Khera et al, utilized data from the Dallas Heart Study and the Dallas-Fort Worth Hospital Council Database from 2000 to 2018 to examine the relationship between factors such as race or sex and cumulative lifetime health care expenses. They found that lifetime health care expenses were substantially higher in Black individuals and men, and increased substantially with increases in cardiovascular risk factors, with many of these differences emerging after age 60. This study was presented in the Addressing Critical Questions of Health Equity and CVD Session.

Association of Cumulative Social Risk Score With Cardiovascular Outcomes in the Multi-Ethnic Study of Atherosclerosis (MESA) [Oral Presentation]

This study, conducted by Hammoud et al, utilized data from the prospective Multi-Ethnic Study of Atherosclerosis (MESA) cohort to assign a social disadvantage score (SDS) to MESA Participants based on income level, education level, single-living status and perception of lifetime discrimination (e.g. mistreated by neighbors, mistreated by police, etc.). They examined association between SDS and atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality; they found that as social disadvantage score increased, so too did incidence of ASCVD and all-cause mortality. This research was presented in the Social Determinants of Cardiovascular Health Session.

Neighborhood Social Vulnerability is Associated With Major Adverse Cardiovascular Events and Deaths Among Patients Hospitalized with COVID-19: An Analysis of the AHA COVID-19 Cardiovascular Disease Registry [Poster presentation]

This study, conducted by Islam et al, utilized data from the American Heart Association COVID-19 Cardiovascular Health Registry to examine the association between neighborhood social vulnerability and major adverse cardiovascular events for patients hospitalized with COVID-19. They found that patients who resided in more socially vulnerable neighborhoods and were hospitalized with COVID-19 were more likely to experience adverse cardiovascular events during their hospitalization.

Income and Antiplatelet Adherence Following Acute Coronary Syndrome: An Administrative Claims Analysis [Oral Presentation]

This study, conducted by LaRosa et al, utilized data from a large and diverse health claims database to examine the association between household income status and antiplatelet adherence. They found that lower income status was associated with a greater likelihood of non-adherence with antiplatelet therapy after primary coronary intervention for acute coronary syndrome. This study was presented in the Social Determinants of Cardiovascular Health Session.

The Association of Social Risk Factors with Hypertrophic Cardiomyopathy Procedures and Mortality: US Nationwide Inpatient Sample, 2012-2018

This study, conducted by Johnson et al, utilized data form the U.S. Nationwide Inpatient Sample to examine the association between social risk factors, septal reduction therapy (e.g. septal myomectomy and alcohol septal ablation), ICD implantation and in-hospital mortality for patients with hypertrophic cardiomyopathy (HCM). They found significant heterogeneity in these outcomes by patient race, sex, income status and rurality.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

Health Equity, the Forgotten Pillar

November 15, 2021November 15, 2021 Ayana April Sanders, PhD

This year’s AHA21 Scientific Session placed an intense spotlight on understanding and achieving health equity in cardiovascular health (CVH). AHA has a broad vision for being transformative in all of the ways that structural inequities influence health outcomes. Specifically, AHA’s 2024 Impact Goal states that: Every person deserves the opportunity for a full, healthy life. As champions for health equity, by 2024, the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality.

On Day 1 of AHA21, during the ‘Cardiovascular Health After 10 Years: What Have We Learned and What is the Future?’ session, we engaged with experts about the genesis of CVH, how it has been studied throughout the life span over the past decade, and methods for influencing CVH at critical life stages. Darwin Labarthe, MD, MPH, PhD, provided a historical review of the conceptual origins and definition of CVH, and the meaning of CVH in translation. CVH is defined by key features of AHA’s Life’s Simple 7, including assessments of diet, smoking status, physical activity, weight management, blood pressure, cholesterol, and blood glucose.

Ideal CVH is determined by the absence of clinically diagnosed CVD together with the presence of the 7 metrics. Longitudinal evidence has shown that maintaining ideal CVH is more cardioprotective than improving and achieving CVH from a lower CVH level. But US NHANES data shows that about 13% of adults meet 5 of the 7 criteria, 5% have 6 of 7, and virtually 0% have ideal CVH or meet 7 of 7 metrics. This begs the question of how do we attain and maintain a high level of CVH? Ideally, maintaining CVH by Life Simple 7 standards should be SIMPLE…just ensure that all 7 metrics are met, and you will have ideal CVH! But realistically, it is near impossible for individuals to achieve ideal CVH. It is more likely that both individual and population-level efforts are needed to achieve and maintain CVH.

From a life course perspective, high CVH in adulthood is more likely when high CVH is present in early life. But as the panelist continued to describe the state of CVH in America, we quickly learned that while high CVH is consistently associated with lower risk of cardiovascular disease (CVD), disparities in CVD rates vary by sociodemographic factors like age, sex, race/ethnicity, and educational attainment. A recent study by panelist Amanda Marma Perak, MD, MS, FAHA, FACC, and colleagues (2020) using data from the CARDIA study found that less than a third of young adult participants had high CVH, and this was lower for Blacks than Whites and those with lower than higher educational attainment. These results demonstrate that CVH is far from ideal even among younger cohorts. Over the last few decades, we have witnessed increasing rates of cardiovascular abnormalities and subclinical and overt CVD in adolescents and emerging or young adults. The low prevalence of ideal CVH in young adults suggests that factors contributing to CVD risk may be embedded at earlier life stages. The experiences that happen or do not happen in early life settings (i.e., family, households, schools, communities, etc.) are important opportunities to achieve or maintain high CVH. The drivers of health disparities, like social determinants of health (SDOH), structural racism, and rural health inequalities, are necessary to achieve sustainable health equity and well-being for all. One method is effectively developing culturally-tailored community-engaged partnerships to promote CVH. LaPrincess Brewer, MD, MPH, shared the phenomenal community-based interventions being conducted to intervene on low CVH in Black neighborhoods by addressing SDOH at the community-level. These included the Fostering African-American Improvement in Total Health CVH (FAITH!) CVH wellness program, Community Health Advocacy and Training (CHAT) program, and The Black Impact Program.

The conversation on CVH and health equity continued strong on Day 2 of AHA21 at the ‘Achieving Health Equity: Advancing to Solutions’ session. With a panel of leading experts in health equity research, calls for action rang out at each presentation. David Williams, PhD, argued that racial inequalities in health are fortified from centuries of established institutional/structural racism, individual discrimination, and cultural racism, which result in a significant cost to mental health and millions of African-American lives lost each year. Sonia Angell, MD, MPH built on the discussion with a call to action in investing in understudied and marginalized communities that experience poorer CVH. Importantly, as clinicians, research scholars, and policymakers, we need to consider the significant impact of spending more time addressing intervention areas with the largest impact on health, like the structural causes of health inequities. When we work to eliminate structural causes of health inequities, we can begin to spend less time and energy working on small impact areas like counseling, education, and referrals for emergency foods and housing. Ultimately, we can reduce the time and costs of mitigating health inequities when we focus on eliminating the structural causes of health inequities.

Finally, in a powerful video, Health Equity: Patients’ Perspectives, we were invited to hear the stories and experiences of those from Black and Hispanic/Latino communities who were significantly affected by health inequities and failed by their healthcare systems. The tales were jarring and left the audience and panel with a strong sense of remorse. The impact of inequalities in health has been a regular staple in marginalized communities across America for centuries. Collectively, from these voices, we recognize that patients and participants need to be treated as humans. In seeking to meet AHA’s 2024 Impact Goal, I want to echo the sentiments of Kirsten Bibbins-Domingo, PhD, MD, MAS, that equity was always an important pillar in health quality and safety, but it is the forgotten pillar. We must make health equity front and center. As such, we need to 1) actively make health equity a priority and place it front and center in our professional and personal work; 2) have respect for all of humanity from all social groups; and 3) we need better science to understand how risk and disease are being experienced.

References

Lloyd-Jones, Donald M., et al. “Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond.”Circulation 4 (2010): 586-613.
Enserro, Danielle M., Ramachandran S. Vasan, and Vanessa Xanthakis. “Twenty‐year trends in the American Heart Association cardiovascular health score and impact on subclinical and clinical cardiovascular disease: the Framingham Offspring Study.”Journal of the American Heart Association 11 (2018): e008741.
Benjamin, Emelia J., et al. “Heart disease and stroke statistics—2017 update: a report from the American Heart Association.”circulation 10 (2017): e146-e603.
Perak, Amanda M., et al. “Associations of late adolescent or young adult cardiovascular health with premature cardiovascular disease and mortality.”Journal of the American College of Cardiology 23 (2020): 2695-2707.
He, Jiang, et al. “Trends in Cardiovascular Risk Factors in US Adults by Race and Ethnicity and Socioeconomic Status, 1999-2018.”JAMA 13 (2021): 1286-1298.

From Race-Based Medicine to Fighting Structural Racism

August 5, 2020August 5, 2020 Elizabeth Knight, PhD, DNP

“Race is the child of racism, not the father.”

-Ta-Nehisi Coates, Between the World and Me.

BiDil, a combination of isosorbide dinitrate and hydralazine, was approved by the FDA in 2005 to treat heart failure in African Americans— the first race-based indication in the U.S. Though some groups lauded this move as a win for the underserved Black community, controversy soon emerged— and rightly so. Why did the researchers come to the conclusion that this combination of drugs worked better for one racial group than another? Why did the FDA take the action to approve it this way? The answers were not reassuring.

Did you know that there is no genetic basis for discrete racial categories? If not, this is likely because of what you were taught in training. It’s time to unlearn some falsehoods! The concept of race is not, in fact, biological, but social. It is not race, but racism that creates and perpetuates inequities.

Race-based medicine is bad medicine. Period. Dorothy Roberts gave a seminal TED talk in 2015 explaining this concept. The persistent myths that characteristics like pain tolerance vary by race are damaging and false. It is up to us, as clinicians and scientists, to dismantle the racist structures and processes within health care and within our larger communities that harm people of color. We cannot allow the fiction of biological racial difference to obscure the reality of racism.

Race can be an important variable to include, analyze, and understand in science and medicine, but not because of biology— because of structural racism. Diagnosis and treatment should not differ by race. Rather, social determinants of health must be part of all the care we provide, and all the research we conduct. We need to fundamentally reexamine the characteristics we use to ensure diversity and external validity. Yes, we need data on race, that that’s not enough.

As we see stark and alarming differences in COVID-19 among racial groups, the realities of racism’s health impacts are writ large. Living and working conditions, rather than biological differences, drive the differential infection and death rates. We, as the next generation of scientists and clinicians, can seize this moment to create lasting change and move toward health equity.

How?

Question assumptions. Race-based decisions in medicine are often due to force of habit, tradition, and education. Ask why and if there’s not a good reason, stop. Why do we give race as a defining characteristic in our case presentations? Why do we calculate creatinine clearance differently? Why do we prescribe differently?
Assess your biases. Try the Harvard bias test, for example. No one is without bias! Seek out training. Eradicate blind spots. Form accountability groups with colleagues. This work can be uncomfortable, but it’s necessary.
Solicit input. Whether you are a researcher or a clinician, the community you serve needs to be involved. Do not assume you always know what’s best. If you ask, and listen, you will discover the values and priorities of the community. Trust-building takes work and time. Demonstrate trustworthiness and remember that iatrophobia is justified by history.
In research, define race and specify the reason for its inclusion. Use a sociopolitical rather than biological framework, and name contributing factors. Name racism and related forms of oppression that may be operating[1].
In clinical care, assess and address social determinants of health. Advocate for equity-focused community practices: food banks, suspension of evictions, support for access to broadband internet to increase access to healthcare and education, and provision of paid time off for sick leave & quarantine, among other actions. Identify needed resources and provide them.[1]

Sustainable change is never straightforward, never easy, and rarely rapid. As early-career professionals, we have many years to fight this fight. Let’s not waste any of them.

References:

[1]Boyd, R., Lindo, E., Weeks, L., & McLemore, M. (2020). On Racism: A New Standard For Publishing On Racial Health Inequities. Health Affairs Blog.

https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/?utm_medium=social&utm_source=twitter&utm_campaign=blog&utm_content=Boyd&

[1] Haynes, N., Cooper, L., & Albert, N. (2020). At the Heart of the Matter: Unmasking and Addressing the Toll of COVID-19 on Diverse Populations. Circulation, 142 (2).

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.048126